Editing Post-traumatic stress disorder (section)

== Diagnosis ==
PTSD can be difficult to diagnose, because of:
* the subjective nature of most of the diagnostic criteria (although this is true for many mental disorders); 
* the potential for [[Malingering of post-traumatic stress disorder|over-reporting]], e.g., while seeking disability benefits, or when PTSD could be a [[mitigating factor]] at criminal sentencing<ref>{{cite journal |title=Fake Posttraumatic Stress Disorder (PTSD) Costs Real Money |journal={{ill|The Inquisitive Mind|de|In-Mind Magazin}} |year=2018 |vauthors=Boskovic I, Merckelbach H |volume=4 |issue=36 |url=https://www.in-mind.org/article/fake-posttraumatic-stress-disorder-ptsd-costs-real-money |access-date=2021-09-30}}</ref>
* the potential for under-reporting, e.g., stigma, pride, fear that a PTSD diagnosis might preclude certain employment opportunities;
* symptom overlap with other mental disorders such as obsessive compulsive disorder and generalized anxiety disorder;<ref>{{cite book |vauthors=First MB |title=DSM-5® Handbook of Differential Diagnosis |date=2013 |publisher=American Psychiatric Pub |isbn=978-1-58562-998-5 |page=225 |url=https://books.google.com/books?id=haOvBAAAQBAJ&pg=PA225 |via=[[Google Books]]}}</ref>
* association with other mental disorders such as major depressive disorder and generalized anxiety disorder;
* substance use disorders, which often produce some of the same signs and symptoms as PTSD; and 
* substance use disorders can increase vulnerability to PTSD or exacerbate PTSD symptoms or both; and
* PTSD increases the risk for developing substance use disorders.<ref>{{cite journal |last1=Brady |first1=Kathleen |title=Substance Abuse and Posttraumatic Stress Disorder |journal=Current Directions in Psychological Science |date=October 2004 |volume=13 |issue=5 |pages=206–209 |doi=10.1111/j.0963-7214.2004.00309.x |s2cid=145248041 }}</ref>
*the differential expression of symptoms culturally (specifically with respect to avoidance and numbing symptoms, distressing dreams, and somatic symptoms)<ref>{{Citation |title=Trauma- and Stressor-Related Disorders |date=2013-05-22 |work=Diagnostic and Statistical Manual of Mental Disorders |publisher=[[American Psychiatric Association]] |doi=10.1176/appi.books.9780890425596.dsm07 |isbn=978-0-89042-555-8 |s2cid=148757484 |url-access=registration |url=https://archive.org/details/diagnosticstatis0005unse}}</ref>

=== Screening ===
There are a number of PTSD screening instruments for adults, such as the PTSD Checklist for ''DSM-5'' (PCL-5)<ref>{{Cite web |url=https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp |title=PTSD Checklist for DSM-5 (PCL-5) |date=11 May 2017 |website=[[National Center for PTSD]]}}</ref><ref name="PCL-5">{{cite journal |vauthors=Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL |title=The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): Development and Initial Psychometric Evaluation |journal=[[Journal of Traumatic Stress]] |volume=28 |issue=6 |pages=489–98 |date=December 2015 |pmid=26606250 |doi=10.1002/jts.22059}}</ref> and the Primary Care PTSD Screen for ''DSM-5'' (PC-PTSD-5).<ref>{{Cite web |url=https://www.ptsd.va.gov/professional/assessment/DSM_5_Validated_Measures.asp |title=Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) |date=7 April 2017 |website=[[National Center for PTSD]]}}</ref> The 17 item PTSD checklist is also capable of monitoring the severity of symptoms and the response to treatment.<ref name="Shalev 2017" />

There are also several screening and assessment instruments for use with children and adolescents. These include the Child PTSD Symptom Scale (CPSS),<ref>{{Cite web |url=http://www.istss.org/assessing-trauma/child-ptsd-symptom-scale.aspx |title=Child PTSD Symptom Scale |website=[[International Society for Traumatic Stress Studies]] |access-date=14 December 2017 |archive-date=6 October 2019 |archive-url=https://web.archive.org/web/20191006052232/http://www.istss.org/assessing-trauma/child-ptsd-symptom-scale.aspx }}</ref><ref>{{cite journal |vauthors=Foa EB, Johnson KM, Feeny NC, Treadwell KR |s2cid=9334984 |title=The child PTSD Symptom Scale: a preliminary examination of its psychometric properties |journal=[[Journal of Clinical Child Psychology]] |volume=30 |issue=3 |pages=376–84 |date=September 2001 |pmid=11501254 |doi=10.1207/S15374424JCCP3003_9}}</ref> Child Trauma Screening Questionnaire,<ref>{{Cite web |url=http://www.nctsnet.org/content/child-trauma-screening-questionnaire |title=Child Trauma Screening Questionnaire |date=5 Sep 2013 |website=The [[National Child Traumatic Stress Network]] |access-date=14 December 2017 |archive-date=25 December 2017 |archive-url=https://web.archive.org/web/20171225114555/http://www.nctsnet.org/content/child-trauma-screening-questionnaire }}</ref><ref>{{cite journal |vauthors=Kenardy JA, Spence SH, Macleod AC |s2cid=1320859 |title=Screening for posttraumatic stress disorder in children after accidental injury |journal=[[Pediatrics (journal)|Pediatrics]] |volume=118 |issue=3 |pages=1002–9 |date=September 2006 |pmid=16950991 |doi=10.1542/peds.2006-0406}}</ref> and UCLA Post-traumatic Stress Disorder Reaction Index for ''DSM-IV''.<ref>{{Cite web |url=http://www.istss.org/assessing-trauma/ucla-posttraumatic-stress-disorder-reaction-index.aspx |title=UCLA Posttraumatic Stress Disorder Reaction Index |website=[[International Society for Traumatic Stress Studies]] |access-date=14 December 2017 |archive-date=6 October 2019 |archive-url=https://web.archive.org/web/20191006052306/http://www.istss.org/assessing-trauma/ucla-posttraumatic-stress-disorder-reaction-index.aspx }}</ref><ref>{{cite journal |vauthors=Elhai JD, Layne CM, Steinberg AM, Brymer MJ, Briggs EC, Ostrowski SA, Pynoos RS |title=Psychometric properties of the UCLA PTSD reaction index. part II: investigating factor structure findings in a national clinic-referred youth sample |journal=[[Journal of Traumatic Stress]] |volume=26 |issue=1 |pages=10–8 |date=February 2013 |pmid=23417874 |doi=10.1002/jts.21755}}</ref>

In addition, there are also screening and assessment instruments for caregivers of very young children (six years of age and younger). These include the Young Child PTSD Screen,<ref name="Scheeringa Tulane">{{cite web |url=https://medicine.tulane.edu/departments/psychiatry/research/dr-scheeringas-lab/manuals-measures-trainings |title=Young Child PTSD Screen |vauthors=Scheeringa M |publisher=[[Tulane University]] |access-date=8 April 2018 |archive-date=29 August 2021 |archive-url=https://web.archive.org/web/20210829161236/https://medicine.tulane.edu/departments/psychiatry/dr-scheeringas-lab/manuals-measures-trainings }}</ref> the Young Child PTSD Checklist,<ref name="Scheeringa Tulane" /> and the Diagnostic Infant and Preschool Assessment.<ref>{{cite journal |vauthors=Scheeringa MS, Haslett N |title=The reliability and criterion validity of the Diagnostic Infant and Preschool Assessment: a new diagnostic instrument for young children |journal=[[Child Psychiatry and Human Development]] |volume=41 |issue=3 |pages=299–312 |date=June 2010 |pmid=20052532 |pmc=2862973 |doi=10.1007/s10578-009-0169-2}}</ref>

=== Assessment ===
[[Evidence-based assessment]] principles, including a multimethod assessment approach, form the foundation of PTSD assessment.<ref>{{Cite journal |vauthors=Bovin MJ, Marx BP, Schnurr PP |date=2015 |title=Evolving DSM Diagnostic Criteria for PTSD: Relevance for Assessment and Treatment |journal=[[Current Treatment Options in Psychiatry]] |volume=2 |issue=1 |pages=86–98 |doi=10.1007/s40501-015-0032-y |quote=... the use of a multi-measure approach eliminates the bias associated with any given instrument .... |doi-access=free}}</ref><ref>{{cite journal |vauthors=Barnes JB, Presseau C, Jordan AH, Kline NK, Young-McCaughan S, Keane TM, Peterson AL, Litz BT |title=Common Data Elements in the Assessment of Military-Related PTSD Research Applied in the Consortium to Alleviate PTSD |journal=Military Medicine |volume=184 |issue=5–6 |pages=e218–e226 |date=May 2019 |pmid=30252077 |doi=10.1093/milmed/usy226 |doi-access=free}}</ref><ref>{{cite book |vauthors=Weathers FW, Keane TM, Foa EB |chapter=Assessment and Diagnosis of Adults |title=Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies |edition=2nd |veditors=Foa EB, Keane TM, Friedman MJ |location=New York |publisher=Guilford |date=2009 |pages=23–61 |quote="Thus, ample resources are now available to conduct psychometrically sound assessments of trauma survivors in any context, and it is no longer defensible for clinicians to do otherwise.}}</ref>{{rp|25}} Those who conduct assessments for PTSD may use various clinician-administered interviews and instruments to provide an official PTSD diagnosis.<ref>{{cite journal | vauthors = Weathers FW, Marx BP, Friedman MJ, Schnurr PP |title=Posttraumatic Stress Disorder in DSM-5: New Criteria, New Measures, and Implications for Assessment |journal=[[Psychological Injury and Law]] |date=2014 |volume=7 |issue=2 |pages=93–107 |doi=10.1007/s12207-014-9191-1 |s2cid=16911948}}</ref> Some commonly used, reliable, and valid assessment instruments for PTSD diagnosis, in accordance with the DSM-5, include the Clinician-Administered PTSD Scale for the DSM-5 (CAPS-5), PTSD Symptom Scale Interview (PSS-I-5), and [[Structured Clinical Interview for DSM|Structured Clinical Interview for DSM-5]] – PTSD Module (SCID-5 PTSD Module).<ref>{{cite journal |vauthors=Weathers FW, Bovin MJ, Lee DJ, Sloan DM, Schnurr PP, Kaloupek DG, Keane TM, Marx BP |title=The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5): Development and initial psychometric evaluation in military veterans |journal=Psychological Assessment |volume=30 |issue=3 |pages=383–395 |date=March 2018 |pmid=28493729 |pmc=5805662 |doi=10.1037/pas0000486}}</ref><ref>{{cite journal |vauthors=Karimi M, Rahnejat AM, Dabaghi P, Taghva A, Majdian M, Donyavi V, Shahed-HaghGhadam H |title=The Psychometric Properties of the Post-Traumatic Stress Disorder Symptom Scale–Interview Based on DSM-5, in Military Personnel Participated in Warfare |journal=[[Iranian Journal of War & Public Health]] |date=2020 |volume=12 |issue=2 |pages=115–124 |doi=10.29252/ijwph.12.2.115 |s2cid=235026213|doi-access=free }}</ref><ref>{{cite journal |vauthors=Foa EB, Tolin DF |title=Comparison of the PTSD Symptom Scale-Interview Version and the Clinician-Administered PTSD scale |journal=Journal of Traumatic Stress |volume=13 |issue=2 |pages=181–191 |date=April 2000 |pmid=10838669 |doi=10.1023/A:1007781909213 |s2cid=7913088}}</ref><ref>{{cite book |vauthors=First MB, Williams JB, Karg RS, Spitzer RL |title=Structured Clinical Interview for DSM-5 Disorders, Clinician Version (SCID-5-CV) |date=2016 |publisher=[[American Psychiatric Association]] |location=Arlington, VA |isbn=978-88-6030-885-6}}</ref>

=== In the DSM and ICD ===
PTSD was classified as an [[anxiety disorder]] in the DSM-IV, but has since been reclassified as a "trauma- and stressor-related disorder" in the [[DSM-5]].<ref name="DSM5" /> The DSM-5 diagnostic criteria for PTSD include four symptom clusters: re-experiencing, avoidance, negative alterations in cognition/mood, and alterations in arousal and reactivity.<ref name="DSM5" /><ref name="NIH2016" />

The International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) classifies PTSD under "Reaction to severe stress, and adjustment disorders."<ref name="World Health Organization">{{cite web |url=https://www.who.int/classifications/icd/en/bluebook.pdf |title=The ICD-10 Classification of Mental and Behavioural Disorders |publisher=[[World Health Organization]] |pages=120–121 |archive-url=https://web.archive.org/web/20140323025330/http://www.who.int/classifications/icd/en/bluebook.pdf |archive-date=2014-03-23 |url-status=live |access-date=2014-01-29}}</ref> The ICD-10 criteria for PTSD include re-experiencing, avoidance, and either increased reactivity or inability to recall certain details related to the event.<ref name="World Health Organization" />

The [[ICD-11]] diagnostic description for PTSD contains three components or symptom groups (1) re-experiencing, (2) avoidance, and (3) heightened sense of threat.<ref>{{Cite news |url=https://www.who.int/news-room/detail/18-06-2018-who-releases-new-international-classification-of-diseases-(icd-11) |title=WHO releases new International Classification of Diseases (ICD 11) |publisher=World Health Organization |access-date=2018-11-15}}</ref><ref name="Brewin_2017">{{cite journal |vauthors=Brewin CR, Cloitre M, Hyland P, Shevlin M, Maercker A, Bryant RA, Humayun A, Jones LM, Kagee A, Rousseau C, Somasundaram D, Suzuki Y, Wessely S, van Ommeren M, Reed GM |title=A review of current evidence regarding the ICD-11 proposals for diagnosing PTSD and complex PTSD |journal=[[Clinical Psychology Review]] |volume=58 |pages=1–15 |date=December 2017 |pmid=29029837 |s2cid=4874961 |doi=10.1016/j.cpr.2017.09.001 |url=http://mural.maynoothuniversity.ie/11577/1/Hyland_Review_2017.pdf}}</ref> ICD-11 no longer includes verbal thoughts about the traumatic event as a symptom.<ref name="Brewin_2017" /> There is a predicted lower rate of diagnosed PTSD using ICD-11 compared to ICD-10 or DSM-5.<ref name="Brewin_2017" /> ICD-11 also proposes identifying a distinct sub-group with [[Complex Post-Traumatic Stress Disorder]] (CPTSD), who have more often experienced several or sustained traumas and have greater functional impairment than those with PTSD.<ref name="Brewin_2017" />

=== Differential diagnosis ===
A diagnosis of PTSD requires that the person has been exposed to an extreme stressor. Any stressor can result in a diagnosis of [[adjustment disorder]] and it is an appropriate diagnosis for a stressor and a symptom pattern that does not meet the criteria for PTSD.

The symptom pattern for [[acute stress disorder]] must occur and be resolved within four weeks of the trauma. If it lasts longer, and the symptom pattern fits that characteristic of PTSD, the diagnosis may be changed.<ref name=DSM4 />

[[Obsessive compulsive disorder|Obsessive–compulsive disorder]] (OCD) may be diagnosed for [[intrusive thought]]s that are recurring but not related to a specific traumatic event.<ref name=DSM4 />

In extreme cases of prolonged, repeated traumatization where there is no viable chance of escape, survivors may develop [[complex post-traumatic stress disorder]].<ref name="Herman1992">{{cite journal |vauthors=Herman JL |s2cid=189943097 |title=Complex PTSD: A syndrome in survivors of prolonged and repeated trauma |journal=[[Journal of Traumatic Stress]] |date=July 1992 |volume=5 |issue=3 |pages=377–391 |doi=10.1007/BF00977235}}</ref> This occurs as a result of layers of trauma rather than a single traumatic event, and includes additional symptomatology, such as the loss of a coherent sense of self.<ref name="Herman1997">{{cite book |vauthors=Herman JL |title=Trauma and Recovery |date=1997 |publisher=[[Basic Books]] |location=New York |isbn=978-0-465-08730-3 |pages=[https://archive.org/details/traumarecovery00herm_0/page/119 119–122] |edition=2nd |url=https://archive.org/details/traumarecovery00herm_0/page/119}}</ref>